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CV Anesthesia > Test 1 > Flashcards

Test 1 Flashcards

(60 cards)

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1
Q

Major branches of left coronary artery

A

LAD

  • diagonal
  • septal perforator
  • intermediate

Circumflex
- obtuse marginal

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2
Q

Major branches of RCA

A

Acute marginal

PDA (in most)

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3
Q

3 most effective monitors to detect myocardial ischemia

A

ECG (detects ischemia 80% of the time)

PAC

TEE

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4
Q

2 factors which decrease myocardial oxygen supply and increase demand

A

Heart rate

Filling pressures (PCWP)

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5
Q

2 factors affecting coronary perfusion pressure

A

DBP (diastolic blood pressure)

LVEDP (Left ventricle end diastolic pressure)

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6
Q

Formula for coronary perfusion pressure

A

CPP = DBP - LVEDP

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7
Q

Role of HR management in optimizing myocardial oxygen supply and demand

A

LV fills during diastole

Total time in diastole key in perfusion

Modest increase in demand (HR) has major effect on supply

as heart rate foes up, filling time goes down

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8
Q

Hemodynamic variable most commonly associated with myocardial ischemia

A

Heart rate

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9
Q

Four factors that may adversely affect ventricular wall tension

A

Systolic BP

Afterload

LV filling volumes

Myocardial ischemia

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10
Q

Myocardial ischemia effect on wall tension

A

Changes compliance and will have higher pressures for same volume

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11
Q

Effect of IABP on myocardial oxygen supply

A

Augmentation of diastolic pressure resulting in increased coronary perfusion

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12
Q

Effect of IABP on myocardial oxygen demand

A

Reduction in afterload

  • decreased cardiac work, oxygen consumption
  • increased cardiac output
  • decreased hemodynamic abnormalities associated with mechanical defects
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13
Q

Most commonly associated complication associated with CABG

A

A-Fib or rhythm disturbances

MI

Post op bleeding

Stroke

ARF

Post-perfusion syndrome (pump head)

Respiratory failure

Sternal wound infection

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14
Q

Predictors of morbidity/mortality with CABG

A 
Age
Prior MI
MI location
Coagulopathies
CHF
Dysrhythmia
HTN
DM
PVD
cerebrovascular disease
Valvular heart disease
Smoking
Lung disease
ECG abnormalities
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15
Q

Time period most associated with morbidity mortality after MI

A

Within 1 month 35% have repeat MI

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16
Q

2 test measuring ventricular function in pt presenting for CABG

A

TEE

PAC

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17
Q

3 commonly used home meds in pt with CAD presenting for CABG

A

Beta blockers

Calcium channel blockers/ ACE inhibitors

Diuretics/thiazides

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18
Q

6 indications for placement of PAC

A
  • LV dysfx
  • angina w/i 48 hours
  • symptomatic valve disease
  • severe HTN w/ hx of angina
  • large operation with anticipated intravascular volume changes
  • vascular surgery with clamp of major arter
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19
Q

4 uses of PAC data during CABG

A

Measure CO

Detect, to, and trend myocardial ischemia

Measure and optimize ventricular preload and volume

Detect, treat, and trend valve dysfx

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20
Q

Clinical uses of intraoperative TEE during CABD

A

Ventricular function (EF, wall motion)

Wall motion abnormalities

Valve dysfunction

Stenosis or regurgitation

Chamber size may be indicative of dysrhythmia and dysfunction

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21
Q

Phenylephrine dose for CABG

A

30-60 mcg/min vs bolus

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22
Q

Dose for sedative hypnotics for CABG

Midazolam

Propofol

Etomidate

A

Midazolam 3-5 mg

Propofol 20-200mg

Etomidate. 10-20 mg

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23
Q

Opiod induction sequence dosage

Fentanyl

Sufentanil

A

Fentanyl 3-25 mcg/kg

Sufentanil 0.5-1.5 mcg/kg

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24
Q

Effect of fentanyl on volatile agent requirement

Dose of 25 mcg/kg, 50 mcg/kg, 75 mcg/kg, 100 mcg/kg

A

Increasing dosage of fentanyl results in decrease in MAC of volatile

25 mcg/GI = 40% decrease MAC

50 mcg/kg = 55% decrease MAC

75 mcg/kg = 65% decrease MAC

100 mcg/kg = 70% decrease MAC

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25
With high dose fentanyl anesthesia resulting changes in hemodynamics Vs inhalation anesthetic
Increase in HR, MAP, CI, MVO2 Inhalation results in decreased HR, CI, MVO2, MAP
26
Dose of epinephrine associated with extrasystoles when using Isoflurane
7 mcg/kg
27
6 causes of Myocardial ischemia during anesthesia
- coronary artery occlusion - tachycardia - high PCWP/CVP (>12-15) - hypotension - severe hypertension - increased workload or high CO (sepsis)
28
6 signs of myocardial ischemia
- ST segment abnormality - dysrhythmia - conduction abnormality - PA waveform abnormality - decreased myocardial performance (low CI or BP) - wall motion abnormality( echo, visual)
29
Intervention of Nitrates for myocardial ischemia
Decreases wall tension better than anything else
30
Intervention of beta blockers for myocardial ischemia
Decreased contractility and HR **use esmolol not metoprolol**
31
Intervention of calcium channel blocker drugs for myocardial ischemia
Just drop BP Not helpful with anything else
32
5 patient subgroups requiring higher perfusion pressures
- Acute MI/ongoing ischemia - renal/cerebral insufficiency - Left main/left main equivalent - aortic stenosis - chronic hypertension
33
4 potential sources of conduit for bypass grafts for CABG
- LIMA - RIMA - radial - saphenous veins - gastroepiploic
34
Blood pressure maintenance during arterial cannulation
Maintain SBP <100 **if higher can dissect aorta**
35
6 sources of rhythm disturbances associated with surgical manipulation CPB
- atrial cannulation/vent stitch - RFG catheter (retrograde cardioplegia) - pericardiotomy - lap under heart to explore distal - myocardial ischemia - dissecting out heart for redo/pericarditis
36
Heparin dose in prep for CPB Goal ACT after periocardiotomy and prior to aortic cannulation
300 units/kg Goal ACT >400 second
37
Hemodynamic consequences of “mixing” or “RAPing”
Decreases viscosity and circulating norepinephrine levels **decreases SVR**
38
4 goals of cardiopulmonary bypass
- oxygenation of blood and elimination of carbon dioxide (ventilation) - circulation of the blood - systemic cooling and rewarding - diversion of blood from heart to provide bloodless surgical field
39
Cross clamp strategies for distal anastomoses
Distals done with cross clamp on Mammary done last to avoid twisting IMA
40
Cross clamp strategy for proximal anastomoses
Cross clamp removed, partial clamp of aorta for proximal At risk for ischemia until proximal completed
41
Protamine dosing after separation of CPB
10mg test dose after satisfied with heart performance Then 25 mg every minute Typical dose 250 mg **remove aortic cannula with 1/2 protamine dose is in***
42
On CPB blood pressure is
Flow X SVR
43
To reduce flow and separate from CPB (hemodynamics)
SVR is increased
44
Prior to CPB what should you do with PAC
Pull PAC back 2 cm bc easier to perf RA when volume lost to go on CPB
45
Law relating to wall tension
LaPlace’s Law
46
Difference in collateral flow and natural flow r/t perfusion of heart
Collateral flow doesn’t reach subendocardial as well as epicardial
47
5 advantages of OPCAB
Less neuropsychological impairments Fewer inotrope, dysrhythmia postop Improved hemostasis Less need for transfusion and fluids Less postop renal insufficiency
48
6 pt subgroups most likely to benefit from OPCAB
``` >70 yrs old Low EF Redo CABG Significant comorbidities Calcified aorta Pt refusing blood products ```
49
Role of intracoronary shunts for distal anastomoses
Placed after arteriotomy Decreased bleeding CBF maintained though reduced
50
4 methods of display ante of heart for distal anastamosis
Laps Towel Deep pericardial sutures Suction stabilizer devices
51
Effects of displacement on | CO/SV and BP
Decreased RV filling but elevated filling pressures rt RA compression Decreased RV output = underfilled LV = lower SV/CO Decreased CO = decreased BP
52
Effects of displacement on valve function
Vertical position = distortion of MV and TV Significant regurgitation
53
Myocardial ischemia manifestations during OPCAB
Elevated PA ** Deterioration in heart performance ST elevation New RWMA
54
Target vessel positioning associated with biggest decrease in SV and increase in CVP
Circumflex positioning
55
4 strategies to manage Herat rhythm disturbances during OPCAB
``` Lidocaine (esp RCA) Magnesium 2gm (keep K4.0) Nitro during distal anastamosis for spasm ```
56
Heaprin dose ACT goal
1.5-2mg/kg (usually 10,000-15,000 units) —1/2 full CBP dose) 3000 units if vein taken prior to bolus for revascularization Keep ACT >250
57
Usefulness of TEE monitoring
RWMA CI superior to TEE with displacement
58
Order of grafting
``` Colalteralized LAD w. LIMA Proximal before distal Diagonals RCA PDA Circ 2nd and 3rd OM PLA OM Ramus intermediate ```
59
Inferior wall exposure surgical maneuver fo limit hemodynamic compromise
Table flat and retraction sutures relaxed Decreases compression of RA/RV
60
Surgical maneuvers to manage hemodynamic changes
- Order of grafts based on hemodynamic consequences - OR graft most diseased first -close communication with anesth - DPS to bring great vessels and chambers into same plane - open R pleura for lat grafts to avoid compression - lift R sternum to make more space (Towel under R side of retractor) - remove pleurocardial fat

CV Anesthesia (4 decks)

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